PEDIATRIC

RADIOLOGY
Dr. Aras
Introduction
• Plain X-ray of the Chest and Soft tissue of the Neck
are a cost-effective imaging method and are currently
the modality used most frequently for evaluation of
the respiratory system in children.
• Conventional radiography is associated with a very
low level of ionizing radiation exposure.
Soft Tissue Neck Study
• Inspiratory stridor resulting from an upper airway obstruction is
the most frequent indication for a soft tissue neck study in pediatric
patients.
• The common causes of inspiratory stridor in infants and children
include croup, epiglottitis, a foreign body, and an upper airway
mass.
• To obtain optimal diagnostic quality, the neck of the patient
should be extended.
• The standard views consist of both an anteroposterior (AP) view
and a lateral view.
Chest Radiography
• Chest radiography is the imaging study obtained most frequently to
evaluate the respiratory system in pediatric patients.
• The standard chest radiographic views consist of the AP view in
infants and young children (<5 years) and either AP or PA views
in older children, in addition to a lateral view.
• AP, PA, and lateral views of the chest can be obtained with the
patient in the supine or erect position.
When evaluating a CXR there are some points to be taken into
consideration:
1. Penetration: the vertebrae should be just visible through
the heart
2. Centering: the spine of the vertebrae should be equidistant
from the medial end of each clavicle
3. Inspiration: The posterior rib should be seen down to 9th
rib till the diaphragm.
4. Diaphragm should be clearly seen.
5. C/T ratio is less than 60%.
1. Vertebrae are visible.
2. At least 9 posterior ribs are seen.
3. Diaphragm should be clearly seen.
4. Medial ends of the clavicles should be equidistant
Thymus Gland
•Another important feature to recognize in the pediatric
chest is the normal thymic tissue in the anterior
mediastinum.
•Normal thymic tissue should not be confused with a
mediastinal or pulmonary mass.
•The thymus is normally prominent on chest films
during the first few years of life.
•It is less noticeable after 3-4 years of age.
•It is clearly visible to the right or left or both sides of
the mediastinum.
•The usual limits in young children are from the level
of the left brachiocephalic vein to the level of the
pulmonary arteries inferiorly. It may, however,
extend into the neck and down to the level of the
diaphragm in young infants.
•In the right chest it often has a typical sail shape
with a horizontal lower border and an outer border
paralleling the chest wall. It frequently abuts
anterior ribs leading to an undulating appearance.
•The normal thymus is not typically very radiopaque,
but it usually permits visualization of pulmonary
vessels through it, it does not compress the airway or
adjacent vasculature.
•In most neonates, temporary thymic involution is
seen during episodes of acute illness.
•Thymic rebound or regrowth is often seen after
recovery from a severe illness or after chemotherapy.
Thymus Sail Sign (normal)
 Spinnaker sail sign

Thymic sail sign

Pneumothorax
• If the CXR is taken PA erect, then the signs of
Pneumothorax will be the same as adult, with particular
attention should be paid not to miss tension pneumothorax .
• If the CXR is Supine, then the affected hemithorax may
appear hyperlucent (darker than the other lung), especially
the lung bases, with deep sulcus sign being a sign of
pneumothorax.
Area of hyperlucency in Hyperlucent right costophrenic
the right hemithorax angle – “Deep sulcus sign”
Deep sulcus sign in pneumothorax
Pneumothorax:
Hyperlucent left
lung especially
at the lung base.
Pneumonia
• Three patterns of pneumonia are recognized on plain CXR
in pediatric patient:
1. Interstitial pattern: there is increased thickness, haziness
and opacities along the bronchovascular marking, this
usually occur in viral pneumonia.
2. Mass like lesion (Round Pneumonia), remember that the
most common cause of solitary pulmonary opacity in
pediatric CXR is pneumonia (usually bacterial).
3. Consolidation: usually lobar in pattern with silhouette
sign and associated pleural effusion (Usually bacterial).
RSV pneumonia, interstitial pattern
PA and lateral CXR demonstrate a left lower lobe consolidation, representing pneumonia.
Also note the meniscus in the left costophrenic angle indicating a parapneumonic left pleural
effusion
 Silhouette sign
Left hypolucency with loss Left hypolucency with loss
of left hemi-diaphragm of left heart border
Example of a “round pneumonia.” PA and lateral CXR show a round opacity in
the superior segment in the right lower lobe which has the appearance of a mass
Heart Diseases
• Cardiac problems usually manifest as SOB in pediatric cases,
and CXR may shows increased cardiac size (more than
60% C/T ratio) or altered heart shape.
• Common causes of increased cardiac size in pediatric
patients are:
1. Congenital heart diseases
2. Cardiomyopathy
3. Pericardial effusion
Cardiomegaly Normal heart size
Boot-shaped heart Egg on a string sign
Two different cases, one is pleural effusion other is collapse
Note: causes of opaque hemithorax
• Massive pleural effusion
• Atelectasis
• Pneumonectomy
• Fulminating pneumonia (occurs in immunocompromised patients)
• Multiple large cysts.
Congenital Diaphragmatic Hernia
note the:
1. position of the NG tube
2. absence of bowel shadow in the
abdomen
Note
• During intrauterine life the lungs appear hyperechoic because they’re
filled with amniotic fluid. The amniotic fluid expands the lungs, so
they develop. In oligohydramnios, enough fluid won’t enter the lungs
to expand, so the lungs won’t develop properly and after birth the
neonate will have respiratory distress.
• Congenital diaphragmatic hernia can be diagnosed clinically by
presence of bowel sounds on auscultation of the chest.
Asthma
• Radiological investigation may be normal in asthma.
• Expected Findings:
1. Hyperinflation
2. Flattened diaphragm
3. Complications like pneumothorax,
pneumomediastinum … etc.
Hyperinflation
(12 posterior rib are seen) +
Right side basal lucency
(Pneumothorax)
Epiglottitis
• is a serious cause of upper airway obstruction in children. It is
characterized by inflammation and swelling of the epiglottis and the
aryepiglottic folds. Epiglottitis is a life-threatening disease that
requires potential emergent intubation.
• A lateral radiograph reveals swelling and marked enlargement of
the epiglottis that resembles the shape of a thumb.
Epiglottitis in a 5-year-old boy with
respiratory distress and drooling.
A lateral soft tissue neck radiograph
shows a markedly thickened epiglottis
(white arrow), which is referred to as
the “thumb” sign.
The aryepiglottic folds (black arrow)
also are thickened.
Foreign Body
Most patients who present with foreign bodies in the upper airway are children
between 6 months and 3 years of age. The most commonly aspirated foreign
bodies in the upper airway are usually bulky, irregularly shaped, or sharp objects.
Nasal foreign bodies tend to be located on the floor of the nasal passage, some are
lodged in the larynx.

Laryngeal foreign body in a 5-month

-old boy who presented with stridor.
Frontal (A) and lateral (B) radiographs
of the upper airway reveals
an elongated density in the laryngeal
region (arrow) proven
to be a piece of bone.
A nasal foreign body in a boy who presented with nasal congestion and foul-smelling discharge for 1
week.
Frontal (A) and lateral (B) radiographs of the nasal airway show a metallic foreign body (battery;
arrow) in the right nasal cavity.
Battery foreign bodies must be removed emergently.
Imaging
Radiography can be helpful in localizing radiopaque foreign
bodies such as coins, buttons, and batteries, but because most
foreign bodies are radiolucent, management should not be
based solely on imaging.
Plain radiography is sufficient to demonstrate radiopaque upper
airway and esophageal foreign bodies.
On frontal radiographs, coins in the esophagus are seen in face,
whereas coins in the trachea are seen in tangent because of a
posterior gap in the tracheal cartilage rings.
Foreign Body Aspiration
Etiology. Foreign body aspiration into the tracheobronchial airway is a frequent cause of acute
respiratory distress in pediatric patients, especially those between 6 months and 3 years of age.
Only approximately 10% of aspirated foreign bodies within the tracheobronchial airway are radiopaque.
The remaining 90% of nonradiopaque foreign bodies are particularly difficult to diagnose early in
pediatric patients.
Nearly 70% of aspirated foreign bodies lodge in the bronchi, with the right side affected more frequently
than the left side.

Imaging.
Radiographic findings of foreign body aspiration depend on the size, location, duration, and nature of the
aspirated foreign body.
Radiopaque foreign bodies usually are detected easily with radiographic studies, which should include
frontal and lateral films encompassing the upper airway from the nasopharynx to the upper abdomen.
When the foreign body is not radiopaque, careful inspection of the tracheobronchial airway is necessary.
If the foreign object is located in the trachea, the chest radiograph may be normal or may show bilateral
hypoinflation or hyperinflation depending on the degree of obstruction.
Most foreign bodies lodge in the main bronchi.
The chest radiograph may show a variety of findings, the most common of which is a unilateral
hyperlucent lung.
If the bronchial obstruction becomes more complete, postobstructive atelectasis, pneumonia, or
bronchiectasis may develop.
Radiopaque foreign body aspiration in a 4-year-old boy who presented with acute onset of coughing and respiratory distress.
(A) Frontal chest radiograph shows a radiopaque foreign body (arrow) located in the left lower lobe, retrocardiac region.
(B) Lateral chest radiograph confirms the location of the foreign body (arrow) in a left lower lobe bronchus.
Bronchoscopy showed a metallic bottle cap lodged in the left lower lobe bronchus.
Nonradiopaque foreign body aspiration in a 5-year-old girl who presented with persistent coughing
and respiratory distress while eating popcorn.
(A) Frontal chest radiograph obtained at end-inspiration shows mild hyperinflation (asterisk) of the
right lower lobe.
Respiratory distress syndrome (RDS) is a relatively
common condition resulting from insufficient production of
surfactant that occurs in preterm neonates. 

Plain radiograph
• typically diffuse ground glass lungs.
• often tends to be bilateral and symmetrical
• air bronchograms may be evident
• lung whiteout in severe cases

RDS can be safely excluded if the neonate has a normal

chest radiograph at six hours after birth. 
Ricketts
Note the changes in the
Metaphysis and anterior end
of Ribs
Thymoma, Teratoma, Terrible lymphoma, Thyroid
Test?
Approach to Pediatric Chest X-rays
https://www.youtube.com/watch?v=JuHBOhhxSNw